Preferred Medical Network - One Source. Many Solutions.

Preferred Medical Network Referral Form

Phone 1-888-586-4650 or Fax 502-489-5045

Please complete this entire form.
Items in red are required

Patient Information
Name: Sex: M F
Address: Date of Birth:
City/State: Date of Injury:
Zip Code: Type of Injury:
Social Security #: Claim #:
Telephone: Employer/Group:
Carrier/Billing Information
Carrier Name: Contact:
Address: Telephone: Ext:
City/State:    
Zip Code:    
Authorized Physicians
Physician #1: City/State: Telephone#:
Physician #2: City/State: Telephone#:
Authorized Services
Electrotherapy: Prescriptions: Maintenance Supplies:
Purchase  Rental 
 
TENS Purchase
 
 
 
Other Unit:  		Home Delivery
 
Drug Card
30 Days 60 Days
90 Days Indefinitely
Other: 
TENS Supplies
Ostomy
Respiratory
In-Home Health
Other
Durable Medical Equipment
Wheelchair
Hospital Bed
Braces
CPM Machine
Bone Stimulator
Other: 
Comments or Descriptions:
File Attachment:
 
Attach a digital copy of any documentation to this form. Microsoft Word, Plain Text, PDFs, JPEGs, TIFFs and GIFs accepted.
File size must be 2 MB or smaller.
 
Please choose a file: